Form 1092 Personnel Security Data Form- Employee

PERSONNEL SECURITY DATA FORM
EMPLOYEE

OMB Control Number: 3133-0201

National Credit Union Administration
Office of Continuity and Security Management

Section A: Applicant Information
Name (Legal Family)

First (Legal Given)

Social Security Number

Date of Birth MM/DD/YYYY

Middle (or NMN if none)

Other Names Used

Place of Birth (City and State) Country

Suffix
Gender
M

Home Street Address

U.S Citizen?
Yes

F

Naturalized U.S. Citizen
Yes

No

Email Address

No

Phone Number

Section B: Position and OHR Information
Position Description Number

Office/Region Supporting

Dates of Internship, if applicable

What is the Applicant's physical duty station?

NCUA OHR Point of Contact

Other NCUA OHR Point of Contact

Eastern (1)
Central Office

Southern (2)

Western (3)

Field or Remote

NOTES

INSTRUCTIONS
Use: This form, in its entirety, must be submitted for any applicant requiring access to NCUA information, systems, or facilities.
Submission: A typed document is preferred to avoid delays and incorrect information. The applicant's full legal name is required. All
documentation must be submitted by the OHR representative to Personnel Security at [email protected].
Privacy Act: AUTHORITY: 5 CFR § 731 and 736; Executive Order 13467; Executive Order 12968/SEAD 4. Disclosure of the
requested information is not mandatory. PURPOSE: To assist NCUA personnel in making an informed decision regarding suitability
for federal employment, fitness for contract employment, and/or granting of a security clearance. ROUTINE USE(S): In addition to
the disclosures generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act, the information contained herein may specifically be
used to document the outcome of adjudicative determination for the issuance of the HSPD-12 PIV card or the local agency access
badge, and to document the outcome of adjudicative determinations for suitability, fitness, and/or national security clearances.
Contact information is used for communication and authentication purposes. A complete list of Routine Uses is available at NCUA-1,
Personnel Access and Security System (81 FR 12748). EFFECTS OF NOT PROVIDING INFORMATION: The requested information
is needed to process your claim for employment and/or access. Disclosure of your personal information is voluntary. However, failure
to provide the requested information may result in removal from the hiring process. SORN: NCUA-1, Personnel Access and Security
System (81 FR 12748), Office of Personnel Management OPM/Central-9.
Paperwork Reduction Act Statement: This information collection meets the requirements of 44 U.S.C. § 3507, as amended by
section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of
Management and Budget (OMB) control number. The OMB control number for this collection is 3133-0201. We estimate that it will
take 10 minutes to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time
estimate, including suggestions for reducing this burden, or any other aspects of this collection of information to: NCUA, Office of
Continuity and Security Management,1775 Duke Street, Alexandria, VA 22314-3428.

NCUA 1092

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